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Benign Prostatic Hyperplasia

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Benign Prostatic Hyperplasia ... 4 ng/ml Prostatic pathology Correlates with tumor mass Some men with prostate cancer have normal PSA levels BPH SYMPTOMS ... – PowerPoint PPT presentation

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Title: Benign Prostatic Hyperplasia


1
Benign Prostatic Hyperplasia
2
Benign Prostatic Hyperplasia
  • Generalised disease of the prostate due to
    hormonal derangement which leads to enlargement
    of the gland (increase in the number of
    epithelial cells and stromal tissue)to cause
    compression of the urethra leading to symptoms

3
BPHProposed Etiologies
  • Cause not completely understood
  • Reawakening of the urogenital sinus to
    proliferate
  • Change in hormonal milieu with alterations in the
    testosterone/estrogen balance
  • Induction of prostatic growth factors
  • Increased stem cells/decreased stromal cell death
  • Accumulation of dihydroxytestosterone,
    stimulation by estrogen and prostatic growth
    hormone actions

4
BPH facts
  • Occurs in 50 of men over 50 and in 80 of men
    over 80 have BPH
  • BPH progresses differently in every individual
  • Many men with BPH may have mild symptoms and may
    never need treatment
  • BPH does not predispose to the development of
    prostate cancer

5
Benign Prostatic Hyperplasia
6
BPH Pathophysiology
Normal
BPH
BLADDER
Hypertrophied detrusor muscle
PROSTATE
URETHRA
Obstructed urinary flow
Kirby RS et al. Benign prostatic hyperplasia.
Health Press, 1995.
7
BPH Pathophysiology
  • Slow and insidious changes over time
  • Complex interactions between prostatic urethral
    resistance, intravesical pressure, detrussor
    functionality, neurologic integrity, and general
    physical health.
  • Initial hypertrophy?detrussor decompensation?
    poor tone?diverticula formation?increasing urine
    volume?hydronephrosis?upper tract dysfunction

8
Complications
  • Urinary retention
  • UTI
  • Sepsis secondary to UTI
  • Residual urine
  • Calculi
  • Renal failure
  • Hematuria
  • Hernias, hemorroids, bowel habit change

9
Clinical manifestations
  • Voiding symptoms
  • decrease in the urinary stream
  • Straining
  • Dribbling at the end of urination
  • Intermittency
  • Hesitancy
  • Pain or burning during urination
  • Feeling of incomplete bladder emptying

10
Clinical manifestations
  • Irritative symptoms
  • urinary frequency
  • urgency
  • dysuria
  • bladder pain
  • nocturia
  • incontinence
  • symptoms associated with infection

11
Benign Prostatic Hyperplasia
  • Leading to symptom bother and worsened QOL

12
Other Relevant History
  • GU History (STD, trauma, surgery)
  • Other disorders (eg. neurologic, diabetes)
  • Medications (anti-cholinergics)
  • Functional Status

13
Diagnostic Tests
  • History Examination
  • Abdominal/GU exam
  • Focused neuro exam
  • Digital rectal exam (DRE)
  • Validated symptom questionnaire.
  • Urinalysis
  • Urine culture
  • BUN, Cr
  • Prostate specific antigen (PSA)
  • Transrectal ultrasound biopsy
  • Uroflometry
  • Postvoid residual

14
AUA Symptom Score Sheet
International prostate symptom score (IPSS)
  Name       Date 
Not at all Less than 1 time in 5 Less than half the time About half the time More than half the time Almost always Your score
Incomplete emptying Over the past month, how often have you had a sensation of not emptying your bladder completely after you finish urinating? 0 1 2 3 4 5  
Frequency Over the past month, how often have you had to urinate again less than two hours after you finished urinating? 0 1 2 3 4 5  
Intermittency Over the past month, how often have you found you stopped and started again several times when you urinated? 0 1 2 3 4 5  
Urgency Over the last month, how difficult have you found it to postpone urination? 0 1 2 3 4 5  
Weak stream Over the past month, how often have you had a weak urinary stream? 0 1 2 3 4 5  
Straining Over the past month, how often have you had to push or strain to begin urination? 0 1 2 3 4 5  
  
None 1 time 2 times 3 times 4 times 5 times or more Your score
Nocturia Over the past month, many times did you most typically get up to urinate from the time you went to bed until the time you got up in the morning? 0 1 2 3 4 5  
 
Quality of life due to urinary symptoms  Delighted Pleased Mostly satisfied Mixed about equally satisfied and dissatisfied Mostly dissatisfied Unhappy Terrible
If you were to spend the rest of your life with your urinary condition the way it is now, how would you feel about that? 0 1 2 3 4 5 6
Total score 0-7 Mildly symptomatic 8-19
moderately symptomatic 20-35 severely
symptomatic.
  
  
  Total score 0-7 Mildly symptomatic 8-19
moderately symptomatic 20-35 severely
symptomatic.
15
DRE
16
BPHDanger Signs on DRE
  • Firm to hard nodules
  • Irregularities, unequal lobes
  • Induration
  • Stony hard prostate
  • Any palpable nodular abnormality suggests cancer
    and warrants investigation

17
Optional Evaluations and Diagnostic Tests
  • Urine cytology in patients with
  • Predominance of irritative voiding symptoms.
  • Smoking history
  • Flow rate and post-void residual
  • Not necessary before medical therapy but should
    be considered in those undergoing invasive
    therapy or those with neurologic conditions
  • Upper tract evaluation if hematuria, increased
    creatinine
  • Cystoscopy

18
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19
PSA
  • Elevated levels of PSA
  • 0 4 ng/ml
  • Prostatic pathology
  • Correlates with tumor mass
  • Some men with prostate cancer have normal PSA
    levels

20
BPH SYMPTOMSDifferential Diagnosis
  • Urethral stricture
  • Bladder neck contracture
  • Carcinoma of the prostate
  • Carcinoma of the bladder
  • Bladder calculi
  • Urinary tract infection and prostatitis
  • Neurogenic bladder

21
BPH TREATMENT INDICATIONSAbsolute vs Relative
  • Severe obstruction
  • Urinary retention
  • Signs of upper tract dilatation and renal
    insufficiency
  • Moderate symptoms of prostatism
  • Recurrent UTIs
  • Hematuria
  • Quality of life issues

22
Treatment Options
  • Mild to severe symptoms with little bother
  • Manage with watchful waiting.
  • Risk of therapy outweighs the benefit of medical
    or surgical treatment
  • Moderate to severe symptoms with bother
  • Management options include watchful waiting,
    medical management and surgical treatment.

23
Therapy
  • Watchful waiting and behavioral modification
  • Medical Management
  • Alpha blockers
  • 5-alpha reductase inhibitors
  • Combination therapy
  • Surgical Management
  • Office based therapy
  • OR based therapy
  • Urethral stents

24
Watchful Waiting and Behavioral Modification
  • is the preferred management technique in
    patients with mild symptoms and minimal bother
  • AUA score lt 7,
  • 1/3 improve on own.

25
Watchful Waiting and Behavioral Modification
  • Decrease caffeine, alcohol )diuretic effect(
  • Avoid taking large amounts of fluid over a short
    period of time
  • Void whenever the urge is present, every 2-3
    hours
  • Maintain normal fluid intake, do not restrict
    fluid
  • Avoid bladder irritants to include dairy
    products, artificial sweeteners, carbonated
    beverages
  • Limit nighttime fluid consumption
  • BPH symptoms can be variable, intermittent

26
Medical Management
  • Nutritional supplements
  • Saw Palmetto
  • Alpha blockers
  • Doxazosin (Cardura), Terazosin (Hytrin),
    Tamsulosin (Flomax), Alfuzosin (Uroxatral)
  • 5-alpha reductase inhibitors
  • Finasteride (Proscar), Dutasteride (Avodart)
  • Combination therapy
  • Alpha blocker and 5-alpha reductase inhibitor

27
medication
  • Benefits
  • Convenient
  • No loss of work
  • time
  • Minimal risk
  • Disadvantages
  • Expensive
  • Drug Interactions
  • Must be taken every day
  • Manages the problem instead of fixing it

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28
Medical Management
  • Alpha adrenergic receptor blockers
  • promote smooth muscle relaxation in the prostate
  • Relaxation of the muscles facilitates urinary
    flow
  • Doxazosin (Cardura), Terazosin (Hytrin),
    Tamsulosin (Flomax), Alfuzosin (Uroxatral)
  • Side effects postural hypotension, dizziness,
    fatigue,
  • Other problems can occur when pt is also taking
    cardiac or other hypertensive drugs

29
Alpha-Adrenergic Blockers
  • Equal clinical effectiveness
  • Slight differences in adverse event profile
  • Orthostasis (lower in tamsulosin)
  • Ejaculatory dysfunction (higher in tamsulosin)
  • Decreased energy levels
  • Nasal congestion
  • Increase in CHF risk with doxazosin
  • Must titrate doxazosin and terazosin to effective
    levels

30
Medical Management
  • 5 alpha reductase inhibitor ) finasteride
    Proscar(
  • Reduce size of prostate gland by up to 30
  • Blocks the enzyme of 5 alpha reductase which is
    nec, for the conversion of testosterone to
    dihydroxytestostersone
  • Regression of hyperplastic growth
  • Dont work immediately
  • Small effect on symptom score and flow rates

31
5-Alpha Reductase Inhibitors
  • Agents are effective and appropriate treatment
    for patients with lower urinary tract symptoms
    and demonstrable enlargement of the prostate.
  • Average prostate size is 30 ccs. Original
    studies showed benefit only in men with prostate
    sizes greater than 50 ccs.

32
5-Alpha Reductase Inhibitors
  • Finasteride (Proscar) and Dutasteride (Avodart)
  • Less effective for relief of BPH symptoms than
    alpha blockers
  • Adverse events include
  • Decreased libido
  • Worsened sexual function (erectile dysfunction)
  • decrease volume of ejaculation
  • Breast enlargement and tenderness
  • Reduces risk of urinary retention by 3/year.
  • PSA must be doubled if screening for prostate
    cancer

33
Combination Therapy
  • Concomitant use of alpha blockers and 5-alpha
    reductase inhibitors
  • Should be reserved for patients who are at
    significant risk of progression and adverse
    outcome
  • Poor surgical candidate
  • Patient wants to avoid surgery
  • Significant cost associated with dual medications

34
Medical Management
  • Herbal therapy saw palmetto fruit use to
    improve urinary symptoms and urinary flow
  • Problem with herbal therapy long term
    effectiveness

35
surgical treatment
36
Surgical Management
  • Office based therapies
  • Transurethral microwave therapy (TUMT)
  • Transurethral needle ablation (TUNA)
  • Therapies are effective
  • or partially effective for
  • relieving the symptoms of BPH
  • Significant side effects/complications
  • associated with these treatments
  • have prompted a FDA warning

37
Surgical Management
  • OR based therapies
  • Open simple prostatectomy
  • TURP
  • Transurethral incision of the prostate
  • Laser photoselective vaporization of the prostate
    (green light laser PVP)
  • Laser Prostatectomy

38
Surgical Management
  • Patients may select surgical treatment as initial
    therapy if moderate or severe bother is present.
  • Patients who have developed complications of BPH
    (i.e urinary retention, renal insufficiency,
    recurrent UTI) are best treated surgically.
  • New surgical treatment have not demonstrated
    better outcomes than TURP to date.

39
BPH TREATMENTSurgical
  • Indicated for AUA score gt16
  • Transurethral Prostatectomy(TURP) 18 morbidity
    with .2 mortality. 80-90 improvement at 1 year
    but 60-75 at 5 years and 5 require repeat TURP.
  • Transurethral Incision of Prostate (TUIP) less
    morbidity with similar efficacy indicated for
    smaller prostates.
  • Open Prostatectomy indicated for glands gt 60
    grams or when additional procedure needed for
    suprapubic/retropubic approaches

40
TURP
Gold Standard of care for BPH
n
41
the gold standard- TURP
  • Benefits
  • Widely available
  • Effective
  • Long lasting
  • Disadvantages
  • Greater risk of side effects and complications
  • 1-4 days hospital stay
  • 1-3 days catheter
  • 4-6 week recovery

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42
possible side effects of
TURP
  • Greater than 5 risk of
  • Irritative voiding symptoms
  • Bladder neck contracture
  • UTI
  • Risk of incontinence 1
  • Decline in erectile function
  • 65 of retrograde ejaculation
  • TUR syndrome (acute hyponatremia from free water
    absorption)
  • Hemorrhage
  • Bladder spasms



43
Preoperative Goals
  • Restoration of urinary drainage
  • Treatment of any urinary tract infection
  • Understanding of procedure, implications for
    sexual functioning and urinary control

44
Preoperative care
  • Antibiotics
  • Allow pt to discuss concerns about surgery on
    sexual functioning
  • Prostatic surgery may result in retrograde
    ejaculation

45
Postoperative Goals
  • No complications
  • Restoration of urinary control
  • Complete bladder emptying
  • Satisfying sexual expression

46
Postoperative Care
  • Monitoring
  • Continuous irrigation maintain catheter patency
  • Blood clots and hematuria are expected for the
    first 24-36 hours
  • After catheter is removed check for urinary
    retention and urinary stream

47
TURP
  • Sphincter tone may be poor after catheter is
    removed. Kegal exercise pelvic muscle floor
    technique is encouraged. Starting and stopping
    the urinary stream is helpful.
  • Stool softeners to avoid straining
  • Sitting and walking for long periods should be
    avoided

48
Discharge planning
  • Catheter care
  • Managing urinary incontinence
  • Oral fluid intake 2,000-3,000 cc per day
  • Observe for s/s of urinary tract infection
  • Prevent constipation
  • Avoid lifting
  • No driving or intercourse after surgery

49
Surgical approaches for prostatectomy
  • Retropubic
  • Midline abd. incision
  • Perineal
  • Incision between the scrotum and anus
  • Suprapubic
  • Abdominal incision

10/3/2013
49
50
Prostatectomy
  • Complications
  • Bleeding
  • Postoperative pain
  • Risk for infection
  • Erectile dysfunction

10/3/2013
50
51
BPH TREATMENTNew Modalities
  • Minimally invasive (Prostatic Stents,TUNA,TUMT,
    HIFU,Water-induced Thermotherapy)
  • Laser prostatectomy (VLAP,ILC,CLAP,TULIP,HoLRP)
  • Electrovaporization (TUVP,TVRP)

52
heat therapies
  • Destroy prostate tissue with heat
  • Tissue is left in the body and is expelled over
    time (called sloughing)
  • Transurethral Microwave Therapy (TUMT)
  • Transurethral Needle Ablation (TUNA)
  • Interstitial Laser Coagulation (ILC)
  • Water Induced Thermotherapy (WIT)

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53
heat therapies
  • Benefits
  • Office treatments
  • Local anesthesia
  • Minimally invasive
  • Reduced risk of complications as compared to
    invasive surgical TURP
  • Disadvantages
  • Some symptoms will persist for up to 3 months
  • Cannot predict who will respond
  • May require prolonged catheterization

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54
possible side effects of
heat therapies
  • Urinary Tract Infection
  • Impotence
  • Incontinence

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55
Laser Photoselective Vaporization of the Prostate
(Laser PVP)
  • TURP-equivalent 7 year improvement in symptom
    score and urination parameters
  • Decreased risk of bleeding and TUR syndrome,
    otherwise similar adverse effect profile
  • May be done on anti-coagulated patients
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